Actualización en analgesia preventiva y analgesia multimodal / Update on preventive analgesia and multimodal analgesia

Una deficiente calidad del manejo del dolor post operatorio agudo genera aumento en la morbilidad perioperatoria, disminuye la calidad de vida del paciente, aumenta los reingresos hospitalarios y, finalmente, los costes en salud. La analgesia preventiva y multimodal son dos estrategias que han sido implementadas para tratar de optimizar el manejo del dolor. Si bien en la primera, la evidencia es favorable a su empleo, aún no existe un total consenso en esto. A su vez, la analgesia multimodal, al emplear diferentes fármacos y/o técnicas, ha logrado evidenciar de mejor manera su utilidad y los beneficios al implementarla como terapia. En este artículo, revisamos la evidencia que certifica y avala el uso de éstas. Finalmente, a nuestro parecer, lo más importante en el quehacer del clínico, es lograr individualizar la estrategia que usaremos en el manejo del dolor postoperatorio, adaptándonos a las necesidades y el contexto propio de cada uno de nuestros pacientes.

A poor quality of acute postoperative pain management generates an increase in perioperative morbidity, decreases the quality of life of the patient, increases hospital readmissions and finally, increases health costs. Preventive and multimodal analgesia are two strategies that are implemented to try to optimize pain management. Although in the first, the evidence is favorable to its use, there is still no total consensus. At the same time, multimodal analgesia, by using different drugs and/or techniques, has demonstrated, in a better way, its usefulness and benefits when implemented as a therapy. In this article, we review the evidence that certifies and supports the use of these techniques. Finally, in our opinion, the most important thing in the clinician's task is to be able to individualize the strategy that we will use in postoperative pain management, adapting to the needs and context of each one of our patients.

Impacto de la implementación de un protocolo de sedoanalgesia en una unidad de cuidados intensivos pediátricos / Impact of the implementation of a sedation and analgesia protocol in a pediatric intensive care unit

Introducción. La adecuada sedación y analgesia es fundamental en el tratamiento de pacientes que requieren asistencia ventilatoria mecánica (AVM). Se recomienda la utilización de protocolos y su monitoreo; son dispares los resultados reportados sobre adhesión e impacto. Objetivos. Evaluar el impacto de la implementación de un protocolo de sedoanalgesia sobre el uso de benzodiacepinas, opioides y evolución en la unidad de cuidados intensivos pediátricos (UCIP), en pacientes que requieren AVM mayor a 72 horas. Métodos. Estudio tipo antes-después, no controlado, en la UCIP de un hospital pediátrico. Se desarrolló en 3 etapas: preintervención de diagnóstico situacional (de abril a septiembre de 2019), intervención y posintervención de implementación del protocolo de sedoanalgesia, educación sobre uso y monitorización de adherencia y su impacto (de octubre de 2019 a octubre de 2021). Resultados. Ingresaron al estudio 99 y 92 pacientes en las etapas pre- y posintervención, respectivamente. Presentaron mayor gravedad, menor edad y peso en el período preintervención. En la comparación de grupos, luego de ajustar por gravedad y edad, en la etapa posintervención se reportó una reducción en los días de uso de opioides en infusión continua (6 ± 5,2 vs. 7,6 ± 5,8; p = 0,018) y los días de uso de benzodiacepinas en infusión continua (3,3 ± 3,5 vs. 7,6 ± 6,8; p = 0,001). No se observaron diferencias significativas en los días de AVM y en los días totales de uso de benzodiacepinas. Conclusión. La implementación de un protocolo de sedoanalgesia permitió reducir el uso de fármacos en infusión continua.

Introduction. Adequate sedation and analgesia is essential in the management of patients requiring mechanical ventilation (MV). The implementation of protocols and their monitoring is recommended; mixed results on adherence and impact have been reported. Objectives. To assess the impact of the implementation of a sedation and analgesia protocol on the use of benzodiazepines, opioids, and evolution in the pediatric intensive care unit (PICU) in patients requiring MV for more than 72 hours. Methods. Before-and-after, uncontrolled study in the PICU of a children's hospital. The study was developed in 3 stages: pre-intervention for situational diagnosis (from April to September 2019), intervention, and post-intervention for implementation of a sedation and analgesia protocol, education on use, and monitoring of adherence and impact (from October 2019 to October 2021). Results. A total of 99 and 92 patients were included in the study in the pre- and post-intervention stages, respectively. Patients had a more severe condition, were younger, and had a lower weight in the preintervention period. After adjusting for severity and age, the group comparison in the post-intervention stage showed a reduction in days of continuous infusion of opioids (6 ± 5.2 versus 7.6­5.8, p = 0.018) and days of continuous infusion of benzodiazepines (3.3 ± 3.5 versus 7.6 ± 6.8, p = 0.001). No significant  differences were observed in days of MV and total days of benzodiazepine use. Conclusion. The implementation of a sedation and analgesia protocol resulted in a reduction in the use of continuous infusion of drugs.

Manejo Clínico ­ Quirúrgico de pacientes con Fisura Anal en la Unidad de Coloproctología del HECAM / Clinical-Surgical Management of patients with Anal Fissure in the Unit HECAM Coloproctology

La fisura anal es una de las enfermedades más antiguamente descritas, la misma que, ha tenido hasta el momento múltiples tratamientos tanto médicos como quirúrgicos, existiendo controversias en su algoritmo terapéutico. Constituye una de las patologías cuyo diagnóstico y tratamiento corresponde a la Especialidad de Coloproctología, afecta a ambos sexos y a cualquier edad y puede ser aguda o crónica. Proponemos el presente Protocolo para un adecuado manejo de la patología, de manera que sirva de guía en la toma correcta de decisiones basadas en la evidencia y el consenso de quienes integramos la Unidad Técnica de Coloproctología del Hospital de Especialidades Carlos Andrade Marín.

Anal fissure is one of the oldest described diseases, which has so far had multiple medical and surgical treatments, with controversies in its therapeutic algorithm. It is one of the pathologies whose diagnosis and treatment corresponds to the Coloproctology Specialty, it affects both sexes and any age and can be acute or chronic. We propose the present Protocol for an adequate management of the pathology, so that it serves as a guide in the correct decision making based on evidence and consensus of those who integrate the Technical Unit of Coloproctology of the Hospital de Especialidades Carlos Andrade Marín.

Ultrasound-guided continuous costoclavicular block through retrograde stimulating catheter technique for postoperative analgesia in shoulder surgery: a case series

Abstract In five patient undergoing surgery for proximal humerus fracture we investigated into postoperative analgesia provided by continuous costoclavicular block using continuous stimulating catheter. The postoperative pain scores were less than 4 in all patients except in two patients who required intravenous tramadol 50 mg as a rescue analgesic. The radiocontrast dye study executed in two patients revealed contiguous contrast spread through the brachial plexus sheath with the catheter tip in the interscalene space. We propose that a continuous costoclavicular block with a retrograde stimulating catheter is a feasible alternative regional anesthesia technique for postoperative analgesia in shoulder surgery.

Effectiveness in Sterilization of Objects Produced by 3D Printing with Polylactic Acid Material: Comparison Between Autoclave and Ethylene Oxide Methods / Eficácia na esterilização de objetos produzidos pela impressão 3D com material ácido polilático: Comparação entre os métodos autoclave e óxido de etileno

Abstract Objective Due to the popularity of 3D technology, surgeons can create specific surgical guides and sterilize them in their institutions. The aim of the present study is to compare the efficacy of the autoclave and ethylene oxide (EO) sterilization methods for objects produced by 3D printing with polylactic acid (PLA) material. Methods Forty cubic-shaped objects were printed with PLA material. Twenty were solid and 20 were hollow (printed with little internal filling). Twenty objects (10 solid and 10 hollow) were sterilized in autoclave, forming Group 1. The others (10 solid and 10 hollow) were sterilized in EO, composing Group 2. After sterilization, they were stored and referred to culture. Hollow objects of both groups were broken during sowing, communicating the dead space with the culture medium. The results obtained were statistically analyzed (Fisher exact test and residue analysis). Results In group 1 (autoclave), there was bacterial growth in 50% of solid objects and in 30% of hollow objects. In group 2 (EO), growth occurred in 20% of hollow objects, with no bacterial growth in solid objects (100% of negative samples). The bacteria isolated in the positive cases was non-coagulase-producing Staphylococcus Gram positive. Conclusions Sterilization by both autoclave and EO was not effective for hollow printed objects. Solid objects sterilized by autoclave did not demonstrate 100% of negative samples and were not safe in the present assay. Complete absence of contamination occurred only with solid objects sterilized by EO, which is the combination recommended by the authors.

Resumo Objetivo Devido à popularidade da tecnologia 3D, cirurgiões podem criar guias cirúrgicos específicos e esterilizá-los nas suas instituições. O objetivo do presente estudo é comparar a eficácia dos métodos de esterilização por autoclave e óxido de etileno (OE) de objetos produzidos pela impressão 3D com material ácido polilático (PLA, na sigla em inglês). Métodos Quarenta objetos em formato cúbico foram impressos com material de PLA. Vinte eram sólidos e 20 eram ocos (impressos com pouco enchimento interno). Vinte objetos (10 sólidos e 10 ocos) foram esterilizados em autoclave, formando o Grupo 1. Os demais (10 sólidos e 10 ocos) foram esterilizados em OE, compondo o Grupo 2. Após a esterilização, os objetos foram armazenados e encaminhados para cultura. Objetos ocos de ambos os grupos foram quebrados durante a semeadura, comunicando o espaço morto com o meio de cultura. Os resultados obtidos foram analisados estatisticamente (teste exato de Fisher e análise de resíduo). Resultados No grupo 1 (autoclave) houve crescimento bacteriano em 50% dos objetos sólidos e em 30% dos objetos ocos. No grupo 2 (OE) o crescimento ocorreu em 20% dos objetos ocos, com ausência de crescimento bacteriano nos objetos sólidos (100% de amostras negativas). A bactéria isolada nos casos positivos foi Staphylococcus Gram positivo não produtor de coagulase. Conclusões A esterilização tanto em autoclave quanto pelo OE não foi eficaz para objetos impressos no formato oco. Objetos sólidos esterilizados em autoclave não demonstraram 100% de amostras negativas, não sendo seguro no presente ensaio. Ausência completa de contaminação ocorreu apenas com objetos sólidos esterilizados pelo OE, sendo a combinação recomendada pelos autores.

The Effectiveness of Periarticular Anesthetic Infiltration in Postoperative Analgesia of Total Hip Arthroplasty / A eficácia da infiltração periarticular anestésica na analgesia pós-operatória de artroplastia total do quadril

Abstract Objective The present study aims to evaluate the effectiveness of the periarticular hip infiltration technique in the postoperative period of total hip arthroplasty. Methods This is a randomized double-blind controlled clinical trial in patients with femoral neck fractures or hip osteoarthritis submitted to a total hip arthroplasty at our institution. The periarticular infiltration technique consisted of the administration of an anesthetic (levobupivacaine) and a steroid (dexamethasone) agent in the nociceptor-rich tissues of the hip after orthopedic implants placement. The control group received an injection of 0.9% saline into the same tissues. Pain, range of motion, and use of opioid analgesic agents after 24 and 48hours of the procedure were evaluated, as well as the presence of adverse effects, time to resume walking, and total hospitalization time. Results The study evaluated 34 patients. The experimental group required fewer opioid agents between 24 and 48 hours. The reduction in pain scores was greater in the placebo group. Conclusion Periarticular anesthetic infiltration as a method of postoperative analgesia for total hip arthroplasty reduced the rates of opioid intake between 24 and 48hours. It provided no benefits regarding pain, mobility, length of stay, or complications.

Resumo Objetivo Este estudo tem como objetivo avaliar a eficácia da técnica de infiltração periarticular do quadril no pós-operatório de artroplastia total do quadril. Métodos Estudo clínico randomizado duplo-cego controlado. O estudo foi realizado nos pacientes com fratura de colo femoral ou osteoartrose de quadril, submetidos ao procedimento cirúrgico de artroplastia total do quadril em nossa instituição. A técnica de infiltração periarticular consistiu na aplicação da combinação de um anestésico (levobupivacaína) com um corticosteroide (dexametasona) nos tecidos ricos em nociceptores do quadril, após a colocação dos implantes ortopédicos. No grupo controle, foi realizada infiltração de soro fisiológico 0,9% nos mesmos tecidos. Após 24 e 48 horas do procedimento, foram avaliados os quesitos de dor, amplitude de movimentos, uso de analgésicos opióides, presença de efeitos adversos, período do início da deambulação e o tempo total de hospitalização. Resultados Trinta e quatro pacientes foram estatisticamente avaliados no estudo. Foi observada uma redução no consumo de opioides entre 24 e 48 h no grupo experimental. Uma redução maior da pontuação de dor foi observada no grupo placebo. Conclusão A infiltração periarticular anestésica como método de analgesia pós-operatória de artroplastia total do quadril, neste estudo, reduziu as taxas deconsumo de opioides

Effect of magnesium sulfate with ketamine infusions on intraoperative and postoperative analgesia in cancer breast surgeries: a randomized double-blind trial

Abstract Background Opioids are the cornerstone in managing postoperative pain; however, they have many side effects. Ketamine and Magnesium (Mg) are NMDA receptor antagonists used as adjuvant analgesics to decrease postoperative opioid consumption. Objective We assumed that adding Mg to ketamine infusion can improve the intraoperative and postoperative analgesic efficacy of ketamine infusion alone in cancer breast surgeries. Methods Ninety patients aged between 18 and 65 years and undergoing elective cancer breast surgery were included in this prospective randomized, double-blind study. Group K received ketamine 0.5 mg.kg-1 bolus then 0.12 mg.kg-1.h-1 infusion for the first 24 hours postoperatively. Group KM: received ketamine 0.5 mg.kg-1 and Mg sulfate 50 mg.kg-1, then ketamine 0.12 mg.kg-1.h-1 and Mg sulfate 8 mg.kg-1.h-1 infusions for the first 24 hours postoperative. The primary outcome was the morphine consumption in the first 24 hours postoperative, while the secondary outcomes were: intraoperative fentanyl consumption, NRS, side effects, and chronic postoperative pain. Results Group KM had less postoperative opioid consumption (14.12 ± 5.11 mg) than Group K (19.43 ± 6.8 mg). Also, Group KM had less intraoperative fentanyl consumption. Both groups were similar in postoperative NRS scores, the incidence of side effects related to opioids, and chronic neuropathic pain. Conclusion Adding Mg to ketamine infusion can safely improve intraoperative and postoperative analgesia with opioid-sparing effect in cancer breast surgery.

Analgesia por láser de baja potencia en pacientes con tratamiento ortodóncico / Low power laser analgesia in patients with orthodontic treatment i: en

Introducción: El dolor es el síntoma más común luego de la primera activación de la aparatología ortodóncica. El tratamiento analgésico más utilizado es el paracetamol; sin embargo, su uso inhibe la actividad de la ciclooxigenasa y la síntesis de prostaglandinas, lo que puede afectar el mecanismo del movimiento dental y el remodelado óseo. Objetivo: Evaluar la efectividad del láser de baja potencia para el alivio del dolor en pacientes con tratamiento ortodóntico. Métodos: Se realizó un estudio cuasiexperimental de intervención terapéutica, desde enero hasta diciembre de 2020, en 40 pacientes atendidos en la consulta de ortodoncia del Hospital General Docente Dr. Juan Bruno Zayas Alfonso de Santiago de Cuba, en quienes se aplicaría fuerza ortodóncica por primera vez. Estos fueron distribuidos de forma aleatoria en 2 grupos de 20 integrantes cada uno: el de estudio, tratado con láser de baja potencia, y el de control, que recibió medicación convencional (paracetamol). Para la validación estadística de la información se emplearon el porcentaje y la prueba de la t de Student para muestras independientes, con 95 % de confiabilidad. Resultados: Luego de tres sesiones terapéuticas, 90,0 % del grupo de estudio refirió no presentar dolor o sentirlo de forma leve, mientras que del grupo de control solo 10,0 % de los pacientes fue ubicado en cualquiera de las dos categorías anteriores. Existió diferencia significativa entre ambos grupos (p=0,00). Conclusiones: Se demostró que el láser, como terapia alternativa, fue más efectivo que el paracetamol.

Introduction: Pain is the most common symptom after the first activation of orthodontic appliance. The most widely used analgesic treatment is paracetamol; however, its use inhibits cyclooxygenase activity and prostaglandin synthesis, which can affect the mechanism of tooth movement and bone remodeling. Objective: To evaluate the effectiveness of low power laser for pain relief in patients with orthodontic treatment. Methods: A quasi-experimental study of therapeutic intervention was carried out, from January to December 2020, in 40 patients treated at the orthodontic clinic of Dr. Juan Bruno Zayas Alfonso Teaching General Hospital in Santiago de Cuba, in whom orthodontic force was applied for the first time. These were randomly distributed into 2 groups of 20 members each: the study group, treated with low-power laser, and the control group, that received conventional medication (paracetamol). For statistical validation of data, the percentage and the Student's t test for independent samples were used, with 95 % confidence interval. Results: After three therapeutic sessions, 90.0% of the study group reported not presenting pain or feeling it slightly, while only 10.0% of patients in control group were put in any of the two previous categories. There was a significant difference between both groups (p=0.00). Conclusions: Laser, as an alternative therapy, was shown to be more effective than paracetamol.

Percepção dos cuidadores frente a dor pós-operatória pediátrica e cuidados de enfermagem / Percepición de los cuidadores sobre el dolor posoperatorio pediátrico y los cuidados de enfermería / Caregivers' perception of pediatric postoperative pain and nursing care

Objetivo: descrever a percepção dos cuidadores frente a dor pós-operatória pediátrica e cuidados de enfermagem. Método: estudo descritivo, realizado na Unidade de Pediatria de um Hospital Universitário no Paraná com dados coletados mediante formulário sociodemográfico e questionário de Dor de MCGill-Melzack adaptado e análise a partir de estatística descritiva. Resultados: participaram do estudo 24 cuidadores de crianças submetidas a intervenções cirúrgicas, predominantemente, mulheres (22), preponderando as crianças do sexo masculino. Os resultados apresentaram maior utilização de dipirona como analgesia (50%), tendo a maioria dos cuidadores descrito a dor como breve (33,3%). O principal comportamento de dor relatado foi choro (35%). De forma geral, os cuidadores classificaram a assistência de enfermagem como muito boa ou excelente. Conclusão: o profissional de enfermagem, reconhece a dor como um evento importante e presta assistência. O estudo incita a necessidade de padronização de instrumentos de avaliação e manejo da dor pediátrica pós-operatória.

Objective: to describe the perception of caregivers regarding pediatric postoperative pain and nursing care.Method:descriptive study, carried out at the Pediatrics Unit of a University Hospital in Paraná with data collected using a sociodemographic form and an adapted MCGill-Melzack Pain questionnaire and analysis based on descriptive statistics. Results: 24 caregivers of children undergoing surgical interventions participated in the study, predominantly women (22), with a predominance of male children. The results showed a greater use of dipyrone as analgesia (50%), with most caregivers describing the pain as brief (33.3%). The main reported pain behavior was crying (35%). In general, caregivers rated nursing care as very good or excellent.Conclusions: the nursing professional recognizes pain as an important event and provides assistance. The study highlights the need for standardization of postoperative pediatric pain assessment and management instruments.

Objetivo: describir la percepción de los cuidadores sobre el dolor posoperatorio pediátrico y el cuidado de enfermería. Método: estudio descriptivo, realizado en la Unidad de Pediatría de un Hospital Universitario de Paraná con datos recolectados mediante formulario sociodemográfico y cuestionario MCGill-Melzack Pain adaptado y análisis con base en estadística descriptiva. Resultados: participaron del estudio 24 cuidadores de niños sometidos a intervenciones quirúrgicas, predominantemente mujeres (22), con predominio de niños varones. Los resultados mostraron un mayor uso de dipirona como analgesia (50%), con la mayoría de los cuidadores describiendo el dolor como breve (33,3%). La principal conducta de dolor reportada fue el llanto (35%). En general, los cuidadores calificaron la atención de enfermería como muy buena o excelente. Conclusiones: el profesional de enfermería reconoce el dolor como un evento importante y brinda asistencia. El estudio destaca la necesidad de estandarizar los instrumentos de evaluación ymanejo del dolor pediátrico posoperatorio.

Laser de baixa potência na cicatrização e analgesia de lesões mamilares: ensaio clínico / Low lavel laser in the healinh and analgesia of nipples trauma: clinical trial / Láser de baja potencia en la curación y analgesia de pezones juveniles: un ensayo clínico

Objetivo: Analisar a eficácia do laser de baixa potência, modalidade local e sistêmico, para cicatrização e redução da dor ocasionadas por lesões mamilares. Métodos: Ensaio clínico, randomizado e controlado realizado com 54 lactantes atendidas em um Banco de Leite Humano, de dezembro de 2017 a junho de 2018. As lactantes, que somaram um total 101 lesões, receberam orientações referentes ao manejo clínico das mamas e foram alocadas em: Grupo Controle (GC), Grupo Laser Local (GLL), que receberam laser diretamente no mamilo lesionado e Grupo Irradiation Laser Intravascular of Blood (GILIB), que receberam a laserterapia sistêmica. Os dados foram analisados no SPSS para avaliação da homogeneidade dos grupos (Kruskal-Wallis) e regressão linear para identificação do efeito da intervenção no tamanho das lesões mamárias e intensidade da dor. Resultados: Os três grupos de análise se mostaram homogêneos antes do experimento (p=0,191). Após a intervenção, houve cicatrização das lesões nos três grupos, sendo significativamente maior no GLL e GILIB (p<0,050). Quanto à dor, houve redução em até 4.0 pontos no GLL e GILIB (p=0,002). Conclusão: A administração da laserterapia local e sistêmica foi mais eficaz para a cicatrização das lesões mamilares e redução da dor, quando comparadas ao grupo controle. (AU)

Objective: To analyze the effectiveness of the low-potency laser, local and systemic, for the healing and reduction of pain caused by nipple trauma. Methods: Clinical, randomized and controlled trial carried out with 54 lactating women assisted in a Human Milk Bank, from December 2017 to June 2018. The lactating women, which totaled 101 lesions, received guidance on the clinical management of their breasts and breasts designated in: Control Group (CG), Local Laser Group (GLL), which received laser directly on the injured nipple, and Intravascular Blood Laser Irradiation Group (GILIB), which received systemic laser therapy. Data were analyzed using the SPSS to assess the homogeneity of the groups (Kruskal-Wallis) and the linear regression to identify the effect of the intervention on the size of breast lesions and the intensity of pain. Results: The three analysis groups were homogeneous before the experiment (p=0.191). After the intervention, the healing of the lesions in the three groups was significantly higher in GLL and GILIB (p<0.050). As for the pain, there is a reduction of up to 4.0 points in GLL and GILIB (p=0.002). Conclusion: The administration of local and systemic laser therapy was more effective for the cure of nipple trauma and pain reduction, in comparison with the control group. (AU)

Objetivo: Analizar la efectividad del láser de baja potencia, local y sistémico, para la cicatrización y reducción del dolor causado por las lesiones del pezón. Métodos: Ensayo clínico, aleatorizado y controlado realizado con 54 mujeres lactantes atendidas en un Banco de Leche Humana, de diciembre de 2017 a junio de 2018. Las mujeres lactantes, que totalizaron 101 lesiones, recibieron orientación sobre el manejo clínico de las mamas y fueron asignadas en: Grupo de Control (CG), Grupo de Láser Local (GLL), que recibió láser directamente en el pezón lesionado, y Grupo de Irradiación de Láser Intravascular de Sangre (GILIB), que recibió terapia con láser sistémico. Los datos se analizaron mediante el SPSS para evaluar la homogeneidad de los grupos (Kruskal-Wallis) y la regresión lineal para identificar el efecto de la intervención sobre el tamaño de las lesiones mamarias y la intensidad del dolor. Resultados: Los tres grupos de análisis eran homogéneos antes del experimento (p=0,191). Tras la intervención, hubo curación de las lesiones en los tres grupos, siendo significativamente mayor en GLL y GILIB (p<0,050). En cuanto al dolor, hubo una reducción de hasta 4,0 puntos en GLL y GILIB (p=0,002). Conclusión: La administración de la terapia con láser local y sistémica fue más efectiva para la curación de las lesiones del pezón y la reducción del dolor, en comparación con el grupo de control. (AU)

Conhecimento e percepção de enfermeiros frente à sedação paliativa na oncologia / Knowledge and perception of nurses dealing with palliative sedation in oncology / Conocimiento y percepción de los enfermeros frente a la sedación paliativa en oncología

Objetivo: compreender o conhecimento e a percepção de enfermeiros quanto à sedação paliativa em oncologia. Método: estudo qualitativo, exploratório e descritivo, com delineamento transversal. Participaram do estudo 16 enfermeiros atuantes na oncologia de um hospital de referência localizado ao norte do Rio Grande do Sul. A coleta de dados ocorreu por meio de entrevista gravada com duração de aproximadamente 10 minutos, sendo aplicado um roteiro de perguntas fechadas com a finalidade de caracterizar os enfermeiros participantes da pesquisa, e perguntas abertas e específicas para contemplar o objetivo do estudo. O método utilizado para o diagnóstico e verificação dos dados da pesquisa foi a análise de conteúdo de Bardin. Os dados foram analisados e codificados por meio do software NVivo 10, que gerou categorias de similaridade e correlações. Resultados: surgiram cinco categorias intituladas "Conhecimento sobre sedação paliativa; Percepção sobre sedação paliativa na oncologia; Sentimentos em relação à sedação paliativa aos pacientes oncológicos; Vivência em relação à sedação paliativa em pacientes oncológicos e Participação do enfermeiro no procedimento de sedação paliativa". Conclusão: o enfermeiro atua de forma efetiva e fundamental na prestação do cuidado e na avaliação do paciente em sedação paliativa, mas ainda encontram-se diversos obstáculos relacionados à participação na tomada de decisões. Evidencia-se a importância de novas pesquisas sobre a temática, como também a implementação de protocolos que subsidiem na indicação da sedação paliativa.(AU)

Objective: to understand the knowledge and perception of nurses dealing with palliative sedation in oncology. Method: this is a qualitative, exploratory, and descriptive study, with a cross-sectional design. The study included 16 nurses working in oncology at a reference hospital located in the north of Rio Grande do Sul. Data were collected through recorded interviews lasting approximately 10 minutes, with a script of closed questions being applied to characterize the nurses participating in the research, and open and specific questions, to contemplate the objective of the study. The method used for the diagnosis and verification of research data was Bardin's content analysis. Data were analyzed and coded using the NVivo 10 software, which generated categories of similarity and correlations. Results: five categories emerged: (i) Knowledge about palliative sedation; (ii) Perception of palliative sedation in oncology; (iii) Feelings regarding palliative sedation in cancer patients; (iv) Experience with palliative sedation in cancer patients; and (v) Participation of the nurse in the palliative sedation procedure. Conclusion: nurses act effectively and fundamentally in providing care and evaluating patients undergoing palliative sedation, but there are still several obstacles related to their participation in decision-making. The importance of new research on the subject is evident, as well as the implementation of protocols that support the indication of palliative sedation.(AU)

Objetivo: comprender el conocimiento y la percepción de los enfermeros sobre la sedación paliativa en oncología. Método: estudio cualitativo, exploratorio y descriptivo, con diseño transversal. El estudio abarcó 16 enfermeros que trabajaban en oncología en un hospital de referencia localizado en el norte de Rio Grande do Sul. La colecta de datos ocurrió por medio de entrevista grabada con duración aproximada de 10 minutos, siendo aplicado un guión de preguntas cerradas con la finalidad de caracterizar los enfermeros participantes de la investigación, y preguntas abiertas y específicas para contemplar el objetivo del estudio. El método utilizado para el diagnóstico y verificación de los datos de la investigación fue el análisis de contenido de Bardin. Los datos fueron analizados y codificados utilizando el software NVivo 10, que generó categorías de similitud y correlaciones. Resultados: surgieron cinco categorías tituladas "Conocimientos sobre sedación paliativa; Percepción de la sedación paliativa en oncología; Sentimientos con respecto a la sedación paliativa para pacientes con cáncer; Experiencia con sedación paliativa en pacientes oncológicos y participación de Enfermeros en el procedimiento de sedación paliativa". Conclusión: el enfermero actúa de forma eficaz y fundamental en la prestación del cuidado y en la evaluación del paciente en sedación paliativa, pero aún existen varios obstáculos relacionados con la participación en la toma de decisiones. Es evidente la importancia de seguir investigando sobre el tema, así como la implementación de protocolos que sustenten la indicación de la sedación paliativa.(AU)

Bilateral versus unilateral erector spinae plane block for postoperative analgesia in laparoscopic cholecystectomy: a randomized controlled study

Abstract Introduction Laparoscopic cholecystectomy (LC) is the common surgical intervention for benign biliary diseases. Postoperative pain after LC remains as an important problem, with two components: somatic and visceral. Trocar entry incisions lead to somatic pain, while peritoneal distension with diaphragm irritation leads to visceral pain. Following its description by Forero et al., the erector spinae plane (ESP) block acquired considerable popularity among clinicians. This led to the use of ESP block for postoperative pain management for various operations. Materials and methods This study was conducted between January and June 2019. Patients aged between 18 and 65 years with an American Society of Anesthesiologists (ASA) physical status I-II, scheduled for elective laparoscopic cholecystectomy were included in the study. All the patients received bilateral or unilateral ESP block at the T8 level preoperatively according to their groups. Results There was no significant difference between the groups in terms NRS scores either at rest or while coughing at any time interval except for postoperative 6th hour (p = 0.023). Morphine consumption was similar between the groups but was significantly lower in group B at 12 and 24 hours (p = 0.044 and p = 0.022, respectively). Twelve patients in group A and three patients in group B had shoulder pain and this difference was statistically significant (p = 0.011). Discussion In conclusion, bilateral ESP block provided more effective analgesia than unilateral ESP block in patients undergoing elective LC. Bilateral ESP block reduced the amount of opioid consumption and the incidence of postoperative shoulder pain.

Asistencia del recién nacido con hernia diafragmática congénita / Care of newborns with congenital diaphragmatic hernia / Cuidados ao recém-nascido com hérnia diafragmática congênita

La hernia diafragmática congénita es un defecto en el diafragma que lleva a la herniación del contenido abdominal a la cavidad torácica durante el período intrauterino. La morbimortalidad está determinada por la asociación con otras malformaciones, el grado de hipoplasia pulmonar y la presencia de hipertensión pulmonar secundaria. Presenta una incidencia estimada de 1 cada 2.500-3.000 recién nacidos vivos, constituyendo en un 60% una malformación aislada. Es una patología evolutiva que puede ser diagnosticada a partir de la semana 20-24, la ubicación más habitual es la posterolateral izquierda. Se trata de una patología que requiere ingreso a cuidados intensivos al nacimiento y luego de lograda la estabilización del paciente es de sanción quirúrgica. Los objetivos de este trabajo son conocer las características generales de la patología para sistematizar el manejo logrando así un óptimo asesoramiento de los padres a nivel prenatal y seguimiento postnatal del recién nacido.

Congenital diaphragmatic hernia is a defect in the diaphragm that leads to herniation of theabdominal contents of the thoracic cavity during the intrauterine period. Morbidity and mortality are determined by the association with other malformations, the degree ofpulmonary hypoplasia and the presence of secondary pulmonary hypertension.It has an estimated incidence of 1 every 2,500-3,000 live newborns, and in 60% of the cases it is an isolated malformation. It is an evolutionary pathology that can be diagnosed from week 20-24; it is most commonly located in the left posterolateral. It is a pathology that requires intensive care at birth and after delivery and once the patient has been stabilized, surgical action is required. The objectives of this work are to understand the general characteristics of the pathology in order to refine its manipulation and achieve optimal counseling for parents at the newborn's prenatal and postnatal stages.

A hérnia diafragmática congênita é um defeito no diafragma que leva à herniação doconteúdo abdominal para a cavidade torácica durante o período intrauterino. A morbimortalidade é determinada pela associação com outras malformações, pelo grau de hipoplasia pulmonar e pela presença de hipertensão pulmonar secundária. Apresenta uma incidência estimada de 1 a cada 2.500-3.000 nascidos vivos, constituindo-se em 60% uma malformação isolada. É uma patologia evolutiva que pode ser diagnosticada a partir da semana 20-24 e a localização mais comum é o póstero-lateral esquerdo. É uma patologia que requer internação em terapia intensiva ao nascimento e após o parto. Uma vez que o paciente for estabilizado, é necessária ação cirúrgica. Os objetivos deste paper são conhecer as características gerais da patologia para melhorar o seu manejo, obtendo assim um aconselhamento ideal para os pais no nível pré-natal e no acompanhamento do crescimento pós-natal do recém-nascido.

Pediatric procedural sedation in African clinical settings: A mixed methods study of African providers' sedation practices

Background: Little is known about the practice of pediatric procedural sedation in Africa, despite being incredibly useful to the emergency care of children. This study describes the clinical experiences of African medical providers who use pediatric proceduralsedation, including clinical indications, medications, adverse events, training, clinical guideline use, and comfort level. The goals of this study are to describe pediatric sedation practices in resource-limited settings in Africa and identify potential barriers to the provision of safe pediatric sedation. Methods: This mixed methods study describes the pediatric procedural sedation practices of African providers using semi-structured interviews. Purposive sampling was used to identify key informants working in African resource-limited settings across a broad geographic, economic, and professional range. Quantitative data about provider background and sedation practices were collected concurrently with qualitative data about perceived barriers to pediatric procedural sedation and suggestions to improve the practice of pediatric sedation in their settings. All interviews were transcribed, coded, and analyzed for major themes. Results: Thirty-eight key informants participated, representing 19 countries and the specialties of Anesthesia, Surgery, Pediatrics, Critical Care, Emergency Medicine, and General Practice. The most common indication for pediatric sedation was imaging (42%), the most common medication used was ketamine (92%), and hypoxia was the most common adverse event (61%). Despite 92% of key informants stating that pediatric procedural sedation was critical to their practice, only half reported feeling adequately trained. The three major qualitative themes regarding barriers to safe pediatric sedation in their settings were: lack of resources, lack of education, and lack of standardization across sites and providers. Conclusions: The results of this study suggest that training specialized pediatric sedation teams, creating portable "pediatric sedation kits," and producing locally relevant pediatric sedation guidelines may help reduce current barriers to the provision of safe pediatric sedation in resource-limited African settings.

Bloqueos supraescapular e interescalénico como analgesia después de la reparación artroscópica del manguito rotador: estudio de cohorte comparativo retrospectivo / Suprascapular and interscalene nerve block as analgesia after arthroscopic rotator cuff repair: a retrospective comparative cohort study

Introducción: El objetivo de este estudio fue comparar la eficacia de los bloqueos interescalénico y supraescapular, solos y combinados, como analgesia posoperatoria en las primeras 3 horas tras la reparación artroscópica del manguito rotador. Materiales y métodos: Estudio de cohorte comparativo retrospectivo, realizado entre 2019 y 2021. El criterio de valoración principal fue el puntaje del dolor de hombro en la sala de recuperación evaluado con una escala analógica visual por el paciente. Los criterios de valoración secundarios fueron el consumo de opioides en la sala de recuperación y las complicaciones de la anestesia locorregional. Resultados: Se incluyó a 175 pacientes, 13 en el grupo de bloqueo interescalénico, 61 en el grupo de bloqueos interescalénico más supraescapular y 101 en el grupo de bloqueo supraescapular. Los grupos de bloqueo interescalénico y de bloqueo interescalénico más supraescapular tuvieron significativamente menos dolor en la sala de recuperación y una tasa total menor de opioides consumidos en miligramos equivalentes de morfina que el grupo de bloqueo supraescapular (p = 0,001 y p <0,01, respectivamente). No hubo diferencias significativas en el dolor ni el consumo de opioides entre el bloqueo interescalénico solo o combinado con bloqueo supraescapular. Conclusiones: El bloqueo interescalénico fue más eficaz que el bloqueo supraescapular para aliviar el dolor y disminuir el consumo de opioides en la sala de recuperación tras la reparación artroscópica del manguito rotador. La combinación de bloqueo interescalénico más bloqueo supraescapular no resultó en un incremento de la eficacia, y se sugiere no combinar estas dos técnicas. Nivel de evidencia: III

Introduction: This study aimed to compare the efficacy of interscalene block (ISB) and suprascapular nerve block (SSNB), individually and in combination (ISB+SSNB), used as postoperative analgesia within the first 3 hours after arthroscopic rotator cuff repair. Materials and methods: Retrospective comparative cohort study, conducted between 2019 and 2021. The primary endpoint was shoulder pain score in the immediate postoperative period as reported on a visual analog scale (VAS) by the patient. Secondary endpoints were opioid use in the recovery room (first 3 hours) and locoregional anesthesia complications. Results:175 patients were included; 13 in the ISB group, 61 in the ISB+SSNB group, and 101 in the SSNB group. The ISB group and the ISB+SSNB group had significantly less pain in the recovery room than the SSNB group (p = 0.001 and p < 0.001, respectively). The percentage of patients who required at least one dose of opioid and the total number of opioids consumed in milligrams of morphine equivalent were significantly lower for the ISB and ISB+SSNB groups than for the SSNB group (p < 0.001). There were no significant differences in pain or opioid use between ISB alone or combined with SSNB (ISB+SSNB). Conclusions: In this retrospective comparative study, ISB was more effective in relieving pain and reducing opioid use in the recovery room after ar-throscopic rotator cuff repair than SSNB. The ISB+SSNB combination did not increase effectiveness, and therefore it is suggested not to combine these two techniques. .Level of Evidence: III

Effect of Wrist-Ankle Acupuncture on Postoperative Analgesia after Total Knee Arthroplasty / 中国结合医学杂志

OBJECTIVE@#To evaluate the effect of wrist-ankle acupuncture (WAA) in pain and functional recovery after total knee arthroplasty (TKA).@*METHODS@#From June to September 2020, 94 participants were included from the Second Hospital of Tangshan and randomly assigned to the WAA group (47 cases) and the sham WAA group (47 cases) by a random number table, receiving real or sham WAA treatment, respectively. The primary outcome measure involved the visual analogue scale (VAS) scores at rest and in motion. The secondary outcomes involved the range of motion (ROM) of the knee joints, straight-leg raising time, postoperative weight-bearing time, sufentanil consumption within 48 h of patient-controlled analgesia (PCA) pump, length of hospital stay, and postoperative complications.@*RESULTS@#The VAS scores on the 3rd, 5th, and 7th postoperative days at rest and in motion was significantly lower in the WAA group than that of the sham WAA group (P<0.01). The ROM on the 1st, 2nd, and 3rd PODs was significantly higher in the WAA group than that of the sham WAA group (P<0.01). In comparison to the sham WAA group, the sufentanil consumption within 48 h of PCA pump was significantly less in the WAA group (156.3 ± 12.2 µg vs. 128.8 ± 9.8 µg, P<0.01). There was no significant difference in active straight-leg raising time, postoperative weight-bearing time, length of hospital stay, and postoperative complications between the two groups (P>0.05).@*CONCLUSIONS@#WAA could alleviate post-TKA pain, improve knee joint function, and reduce the sufentanil consumption within 48 h of PCA pump. WAA is a safe and effective treatment in the perioperative analgesic management for TKA.

Pathogenesis and staging treatment for non-specific low back pain based on the meridian sinew theory / 中国针灸

Based on the physiological and pathological characteristics of meridian sinew theory, the staging treatment of non-specific low back pain (NLBP) is explored to provide the reference of clinical practice. The twelve meridian sinews of the human body communicate with the bones and joints of the whole body, which governs the movement, body protection and defense, and meridian regulation. Physiologically, the meridian sinew maintains the functions of the lumbar region. In pathology, the meridian sinew may encounter stasis and pain, contraction and spasm or "transverse collateral" formation. According to the pathological staging of meridian sinew disorders, the progress of NLBP is divided into 3 phases and the corresponding treatments are provided. Mild stimulation and rapid analgesia is suggested to promote tissue repair at the early phase; muscle spasm is relieved to adjust muscular status at the middle phase; and the "cord-like" muscle foci is removed at the later phase of the disease.